OCCUPATIONAL HEALTH PROGRAM

FOR BLOODBORNE PATHOGENS

(to be completed by McGill staff and students)

To address the health risks which may result from working with human bloodor other potentially infectious materials,McGill University has instituted for its faculty, staff and students an Occupational HealthProgram for Bloodborne Pathogens for those who may risk such exposure as part of their work or research.

Although participation in this Program is voluntary, participation includingHepatitis B immunization is highly recommended to all staff and students who routinely handle or will have exposure to human blood or other potentially infectious materials.

PARTICIPANT INFORMATION:

Name (Last, First)

/

McGill ID number

Department

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Faculty

Title (Dr., Mr., Ms. Etc)

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Classification (PI, PDF, Grad., tech, etc)

Legend:PI principal investigator
PDF post doctoral fellow
GRAD graduate student
TECH technician
UG undergraduatestudent

Email address

SUPERVISOR INFORMATION: / Telephone (local)

Principal investigator or supervisor

/ Email

I hereby confirm that I have reviewed the Occupational Health Programposted on the University’s website at have been informed and understand the risks associated with working with bloodborne pathogens.

I am engaged in the following type of contact:

______Direct:work with human blood or other potentially infectious materials.

______Indirect: work in areas where I may come into contact with human blood or other potentially infectious materials.

Please confirm decision below and sign document.

Ihereby agree to:

______PARTICIPATE in the Occupational Health Programby completing and mailing

(initials)this form to:Environmental Health andSafety, 3610 McTavish 4th floor attn: Kathryn Wiens.

  • If I am a McGill employee, the OHP Administrator will call me to arrange an appointment.
  • If I am aMcGill student, I will call Student Health Services(main campus = 398-6017, Macdonald Campus = 398-7992) for an appointment.

or

______choose to NOT PARTICIPATE in the Occupational Health Programafter

(initials)consulting with my supervisor.

  • I am fully aware of the risks of refusing the Hepatitis B vaccine, and I understand that I may, at anytime, change my decision and decide to participate.

Signature

/

Date (dd-mm-yyyy)